COPD

This is just an overview of Chronic obstructive pulmonary disease

1. Chronic Obstructive Pulmonary Disease(COPD) Melaku Yitbarek(M.D) Internal Medicine Unit March,2018

2. Lecture Outline Defintion Epidemiology Risk factors Pathophysiology Clinical Presentation Diagnosis Treatment

3. Definition Chronic obstructive pulmonary disease (COPD) is defined as a disease state characterized by airflow limitation that is not fully reversible COPD includes emphysema , an anatomically defined condition characterized by destruction and enlargement of the lung alveoli; chronic bronchitis ,a clinically defined conditionWith chronic cough and phlegm; and small airways disease,a condition in which small bronchioles are narrowed

4. Definition…

5. Epidemiology COPD is the third leading cause of death and affects >10 million persons in the United States COPD is also a disease of increasing public health importance around the world. Estimates suggest that COPD will rise from the sixth to the third most common cause of death worldwide by 2020 . In Ethiopia, no adequate epidemiologic data . COPD accounted for 3.6% of chest clinic visit at TASH ( 2014)

6. Risk factors Cigarette smoking-pack year(dose X years) ↓FEV1 faster Airway responsive as in asthma(genetic predisposition) Respiratory infections-childhood(initiate/exacerbate) Occupational exposure-dust,gold,↓FEV1 Air pollution town>rural,↑Women( indoor pollution) +/_ genetic /environmental+passive Genetic – α 1 antitrypsin deficiency(emphysema)

7. Pathophysiology

8. release Inflammatory Process in COPD NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease. April 2001 (Updated 2003). Barnes PJ. Chronic obstructive pulmonary disease. N Engl J Med. 2000;343:269-280. activates Neutrophils Macrophages in respiratory tract Proteases stimulate release Parenchymal Destruction

9. Causes of Airflow Limitation Irreversible Fibrosis and narrowing of the airways Loss of elastic recoil due to alveolar destruction Destruction of alveolar support that maintains patency of small airways Reversible Accumulation of inflammatory cells, mucus, and plasma exudate in bronchi Smooth muscle contraction in peripheral and central airways Dynamic hyperinflation during exercise

10. Pathophysiology in Chronic bronchitis

11. Normal versus Diseased Bronchi

12. Pathophysiology in Emphysema

13. Pathophysiology in Emphysema

14. Emphysema

15. Not only smoking but smoke Air pollution resulting from the burning of wood and other biomass fuels is estimated to kill two million women and children each year.

16. Natural History The effects of cigarette smoking on pulmonary function appear to depend on the intensity of smoking exposure, the timing of smoking exposure during growth, and the baseline lung function of the individual The rate of decline in pulmonary function can be modified by changing environmental exposures (i.e., quitting smoking), with smoking cessation at an earlier age providing a more beneficial effect than smoking cessation after marked reductions in pulmonary function have already developed . Genetic factors likely contribute to the level of pulmonary function achieved during growth and to the rate of decline in response to smoking and potentially to other environmental factors as well

17. Clinical Presentation History: The three most common symptoms in COPD are cough, sputum production,and exertional dyspnea Many patients have such symptoms for months or years before seeking medical attention . Activities involving significant arm work , particularly at or above shoulder level, are particularly difficult for patients with COPD In the most advanced stages , patients are breathless doing simple activities of daily living Patients may also develop resting hypoxemia and require institution of supplemental oxygen

18. Clinical Presentation Physical findings: In the early stages of COPD, patients usually have an entirely normal physical examination In patients with more severe disease, the physical examination is notable for a prolonged expiratory phase and may include expiratory wheezing. In addition , signs of hyperinflation include a barrel chest and enlarged lung volumes with poor diaphragmatic excursion as assessed by percussion Patients with severe airflow obstruction may also exhibit sitting in “Tripod postion ”

19. Clinical Presenatation Physical findings: Patients may develop cyanosis, visible in the lips and nail beds A dvanced disease may be accompanied by cachexia, with significant weight loss, bitemporal wasting Clubbing of the digits is not a sign of COPD, and its presence should alert the clinician to initiate an investigation for causes of clubbing .

20. Laboratory findings The hallmark of COPD is airflow obstruction Pulmonary function testing shows airflow obstruction with a reduction in FEV1 and FEV/FVC With worsening disease severity, lung volumes may increase, resulting in an increase in total lung capacity,functional residual capacity, and residual volume

21. Spirometry

22. Spirometry Volume, liters Time, seconds 5 4 3 2 1 1 2 3 4 5 6 FEV 1 = 1.8L FVC = 3.2L FEV 1 /FVC = 0.56 Normal Obstructive

23. Treatment Stable phase COPD: Only three interventions :smoking cessation, oxygen therapy in chronically hypoxemic patients, and lung volume reduction surgery in selected patients with emphysema—have been demonstrated to influence the natural history of patients with COPD All other current therapies are directed at improving symptoms and decreasing the frequency and severity of exacerbations

24. Tx… Pharmacotherapy: Smoking cessation Bronchodilators Anticholinergics Beta agonists Inhaled corticosteroids Oral corticosteroids Theophyline O2: has mortality benefit

25. Tx COPD Exacerbations: Exacerbations are a prominent feature of the natural history of COPD . Exacerbations are episodes of increased dyspnea and cough and change in the amount and character of sputum The approach to the patient experiencing an exacerbation includes an assessment of the severity of the patient’s illness, both acute and chronic components; an attempt to identify the precipitant of the exacerbation; and the institution of therapy.

26. Tx… Acute COPD Exacerbations: Bronchodilators: Inhaled Beta agonists with anticholinergic agents Antibiotics: azithromycine Glucocorticoids: Oxygen Mechanical Ventilatory support: In pts with respiratory failure, decrease mortality rate

27. Referrences Harrison’s Principles of Internal Medicine,19 th Edition Standard Treatment Guideline for general Hospital 2014 Uptodate 21.6

28. Thank You…